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Terms in this set (125)
The nurse is monitoring neurological vital signs for a male client who lost consciousness after
falling and hitting his head. Which assessment finding is the earliest and most sensitive
indication of altered cerebral function?
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness.
D
(Neurological vital signs include serial assessments of TPR, blood pressure, and components
of the Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary
responses. A change in the client's level of consciousness, as indicated by responses to
commands during the GCS, is the first and the most sensitive sign of change in cerebral
function. The other assessment data choices are late signs of altered cerebral function.)
,A nurse is planning to teach self-care measures to a female client about prevention of yeast
infections. Which instructions should the nurse provide?
a. Use a douche preparation no more than once a month.
b. Increase daily intake of fiber and leafy green vegetables.
c. Select nylon underwear that is loose-fitting, white, and comfortable.
d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts.
D
(A common genital tract infection in females is candidiasis, which is an overgrowth of the
normal vaginal flora of Candida albicans that thrives in an environment that is warm and moist
and is perpetuated by tight-fitting clothing, underwear, or pantyhose made of nonabsorbent
materials. The client should wear clothing that is loose fitting and absorbent, such as cotton
underwear, and avoid using bubble-bath or bath salts which further irritate sensitive genital
tissue. Douching is not recommended because it can irritate vaginal tissue, alter pH, and
contribute to fungal growth. While increasing dietary fiber intake encourages healthy,
nutritional guidelines, it is not the focus of the teaching. Cotton, not nylon undergarments,
provide absorbancy and reduce moisture in the perineal area.)
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most
important for the nurse to implement?
a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room.
D
(Active tuberculosis requires implementation of airborne precautions, so the client should be
assigned to a negative pressure air-flow room. Although isolation gowns and isolation carts
should be implemented for clients in isolation with contact precautions, it is most important that
air flow from the room is minimized when the client has TB. The respirator mask should be
implemented when the client leaves the isolation environment.)
The nurse is planning to conduct nutritional assessments and diet teaching to clients at a
family health clinic. Which individual has the greatest nutritional and energy demands?
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child.
A
A pregnant woman's metabolic demands are 20 to 24% more than the basic metabolic rate.
The other clients require only 15 to 20% more than the basic metabolic rate.
, What nursing delivery of care provides the nurse to plan and direct care of a group of clients
over a 24-hour period?
a. Team nursing.
b. Primary nursing.
c. Case management.
d. Functional nursing.
B
(Primary nursing is a model of delivery of care where a nurse is accountable for planning care
for clients around the clock. Functional nursing is a care delivery model that provides client
care by assignment of functions or tasks. Team nursing is a care delivery model where
assignments to a group of clients are provided by a mixed-staff team. Case management is
the delivery of care that uses a collaborative process of assessment, planning, facilitation, and
advocacy for options and services to meet an individual's health needs and promote quality
cost-effective outcomes.)
Which approach should the nurse use when preparing a toddler for a procedure?
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
c. Plan a teaching session to last about 20 minutes.
d. Show equipment but prevent child from handling it.
A
(Imitation is one of the most distinguishing characteristics of toddler play, so demonstration of
a procedure on a doll enables a non-threatening, dramatic experience that can help prepare
the toddler for the actual procedure. The primary developmental task in toddlerhood is
acquiring a sense of autonomy, so giving choices whenever possible to a toddler is
recommended, not avoiding asking the toddler to make a choice. Since the toddler's attention
span is short, teaching sessions should be brief and can be repeated for reinforcement.
Showing the equipment before its use helps relieve anxiety, but the child should be allowed to
handle some of the equipment to prevent frustration and alleviate fear.)
The nurse is caring for a client who is the daughter of a local politician. When the nurse
approaches a man who is reading the names on the hall doors, he identifies himself as a
reporter for the local newspaper and requests information about the client's status. Which
standard of nursing practice should the nurse use to respond?
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality.
D
(Confidentiality is the nurse's primary responsibility and is supported by HIPAA, which
mandates that personal information is not disclosed and access to sensitive client information
is limited. Caring involves the nurse's concern about how the client experiences the world.
Veracity is the nurse's duty to tell the truth and not deceive others. Advocacy is support of the
client's best interests.)
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Terms in this set (125)
The nurse is monitoring neurological vital signs for a male client who lost consciousness after
falling and hitting his head. Which assessment finding is the earliest and most sensitive
indication of altered cerebral function?
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness.
D
(Neurological vital signs include serial assessments of TPR, blood pressure, and components
of the Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary
responses. A change in the client's level of consciousness, as indicated by responses to
commands during the GCS, is the first and the most sensitive sign of change in cerebral
function. The other assessment data choices are late signs of altered cerebral function.)
,A nurse is planning to teach self-care measures to a female client about prevention of yeast
infections. Which instructions should the nurse provide?
a. Use a douche preparation no more than once a month.
b. Increase daily intake of fiber and leafy green vegetables.
c. Select nylon underwear that is loose-fitting, white, and comfortable.
d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts.
D
(A common genital tract infection in females is candidiasis, which is an overgrowth of the
normal vaginal flora of Candida albicans that thrives in an environment that is warm and moist
and is perpetuated by tight-fitting clothing, underwear, or pantyhose made of nonabsorbent
materials. The client should wear clothing that is loose fitting and absorbent, such as cotton
underwear, and avoid using bubble-bath or bath salts which further irritate sensitive genital
tissue. Douching is not recommended because it can irritate vaginal tissue, alter pH, and
contribute to fungal growth. While increasing dietary fiber intake encourages healthy,
nutritional guidelines, it is not the focus of the teaching. Cotton, not nylon undergarments,
provide absorbancy and reduce moisture in the perineal area.)
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most
important for the nurse to implement?
a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room.
D
(Active tuberculosis requires implementation of airborne precautions, so the client should be
assigned to a negative pressure air-flow room. Although isolation gowns and isolation carts
should be implemented for clients in isolation with contact precautions, it is most important that
air flow from the room is minimized when the client has TB. The respirator mask should be
implemented when the client leaves the isolation environment.)
The nurse is planning to conduct nutritional assessments and diet teaching to clients at a
family health clinic. Which individual has the greatest nutritional and energy demands?
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child.
A
A pregnant woman's metabolic demands are 20 to 24% more than the basic metabolic rate.
The other clients require only 15 to 20% more than the basic metabolic rate.
, What nursing delivery of care provides the nurse to plan and direct care of a group of clients
over a 24-hour period?
a. Team nursing.
b. Primary nursing.
c. Case management.
d. Functional nursing.
B
(Primary nursing is a model of delivery of care where a nurse is accountable for planning care
for clients around the clock. Functional nursing is a care delivery model that provides client
care by assignment of functions or tasks. Team nursing is a care delivery model where
assignments to a group of clients are provided by a mixed-staff team. Case management is
the delivery of care that uses a collaborative process of assessment, planning, facilitation, and
advocacy for options and services to meet an individual's health needs and promote quality
cost-effective outcomes.)
Which approach should the nurse use when preparing a toddler for a procedure?
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
c. Plan a teaching session to last about 20 minutes.
d. Show equipment but prevent child from handling it.
A
(Imitation is one of the most distinguishing characteristics of toddler play, so demonstration of
a procedure on a doll enables a non-threatening, dramatic experience that can help prepare
the toddler for the actual procedure. The primary developmental task in toddlerhood is
acquiring a sense of autonomy, so giving choices whenever possible to a toddler is
recommended, not avoiding asking the toddler to make a choice. Since the toddler's attention
span is short, teaching sessions should be brief and can be repeated for reinforcement.
Showing the equipment before its use helps relieve anxiety, but the child should be allowed to
handle some of the equipment to prevent frustration and alleviate fear.)
The nurse is caring for a client who is the daughter of a local politician. When the nurse
approaches a man who is reading the names on the hall doors, he identifies himself as a
reporter for the local newspaper and requests information about the client's status. Which
standard of nursing practice should the nurse use to respond?
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality.
D
(Confidentiality is the nurse's primary responsibility and is supported by HIPAA, which
mandates that personal information is not disclosed and access to sensitive client information
is limited. Caring involves the nurse's concern about how the client experiences the world.
Veracity is the nurse's duty to tell the truth and not deceive others. Advocacy is support of the
client's best interests.)
